History is a great teacher. Whenever I start to believe that our contemporary issues are new to humanity, I seem to immediately encounter a historical example.
I just finished reading a biography of Civil War General and President Ulysses S. Grant. A lifelong cigar smoker and moderate imbiber, he died of head and neck cancer. Memorably, he wrote his autobiography, encouraged by his editor Mark Twain, which is considered perhaps the best presidential example of the genre of all time, while consciously dying from his cancer.
Unbeknownst to me, he also took time out from writing his memoirs to write some personal thoughts into a diary, including about his cancer. The insights into palliative medicine are remarkable, especially given the continuing ignorance of them in our own day. He writes in a remarkably clear-headed way.
Treating the Pain
Describing the pain and symptoms he was having he says, “…I have watched my pains and compared them with those of the past few weeks. I can feel plainly that my system is preparing for dissolution in three ways: one by hemorrhage, one by strangulation, and the third by exhaustion.” This is a stunningly prescient and dispassionately clinical description of his prognosis, and one that I would be delighted to hear from an intern on my service.
Then, for his doctors, he makes crystal clear his care preferences, “I have fallen off in weight and strength very rapidly for the last two weeks. There cannot be a hope of going far beyond this time. All any physician, or any number of them, can do for me now is to make my burden of pain as light as possible.”
A clearer description of the desire for a palliative approach at the end of life couldn’t be made.
He worries openly about his current family doctor insisting on bringing in more specialists, “I dread them…knowing that it means another desperate effort to save me, and more suffering.”
As he weakened, he recorded his reactions to his pain medications. As his doses of morphine escalated, outlines a distinction between addiction versus normal escalating needs for pain relief, “…when I do take [morphine], it is not from craving, but merely from the knowledge of the relief it gives. If I should go without it all night I would become restless…from the continuous pain I would have to endure.” My patients worry all the time about “becoming addicted” to pain medicines – it would serve me well to simply read this passage in reply.
Existential Suffering…and Triumph
One strategy for normalizing end-of-life situations, as difficult as it is to note at times, is to use humor, something Grant does expertly, “The fact I think I am a verb instead of a personal pronoun. A verb is anything that signifies to be, to do or to suffer. I signify all three.”
Yet all was not seen as bleak.
He appreciated all the more the trials and tribulations the country had endured through that horrible war, and he was glad to have seen it through. “It has enabled me to see for myself the happy harmony which has so suddenly sprung up between those engaged but a few short years ago in a deadly conflict.”
And he was appreciative of the sympathy he received from his recently united fellow citizens. “It has been an inestimable blessing to me to hear the kind of expressions towards me in person from all parts of the country; from people of all nationalities, of all religions, and of no religion, of Confederate and National troops alike, of soldiers’ organizations, of mechanical, scientific, religious and all other societies…They have brought joy to my heart, if they have not effected a cure.” Reflecting on one’s life, even when not as eventful as the general’s, is often cathartic for patients.
And he had the occasional “good days” that I urge my patients to embrace, sitting on his porch, “I feel pretty well…I am as bright and well now, for a time at least, as I ever will be.”
Engaging with Loved Ones to the End
Unable to talk, he wrote a loving farewell to he beloved wife, who was wracked with grief. “With…the knowledge I have of your love and affections and the dutiful affections of all our children, I bid you a final farewell until we meet in another, and I trust better, world.” Like many, he had spiritual needs to satisfy at the very end.
Having finished his memoir and sent it off to the printers, he signed off. “There is nothing more I should do now. Therefore, I am not likely to be more ready to go than at this moment.” He had shrunk down to under 100 pounds; too weak to sit, he retired to bed.
Three days later, his family gathered around him, he died.